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Physician Suicide: A Scoping Review to Highlight Opportunities for Prevention

Tiffany I. Leung, MD, MPH, FACP, FAMIA1*, Sima S. Pendharkar, MD, MPH, FACP2, 1 Chwen-Yuen Angie Chen, MD, FACP, FASAM3, Rebecca Snyder, MSIS4 2

1Faculty of Health, Medicine, and Life Sciences, Department of Internal Medicine, Maastricht 3 University, Maastricht, The Netherlands 4 2The Brooklyn Hospital Center, Division of Hospital Medicine, Icahn School of Medicine at Mount 5 Sinai, Brooklyn, NY, USA 6 3Department of Primary Care and Population Health, Stanford University, Palo Alto, CA, USA 7 4Library Services, University of Texas Southwestern Medical Center, Dallas, Texas, USA 8

* Correspondence: 9 Corresponding Author 10 [email protected] 11

Keywords: Physician Suicide; Burnout, professional; Job satisfaction; Physicians; Suicide; 12 Parasuicide 13

Author Approval: All authors have seen and approved the manuscript. 14

Competing Interests: The authors declare that the research was conducted in the absence of any 15 commercial or financial relationships that could be construed as a potential conflict of interest. 16

Declarations: None 17

Data Availability Statement: The raw data supporting the conclusions of this manuscript will be 18 made available by the authors, without undue reservation, to any qualified researcher. 19

Funding Statement: This work was supported by a Mapping the Landscape Literature Review grant 20 (2017-2019) from the Arnold P. Gold Foundation Research Institute. The Arnold P Gold Foundation 21 Research Institute had no role in the study design, data collection and analysis, writing of the report, 22 or decision to submit the manuscript for publication. 23

All rights reserved. No reuse allowed without permission. not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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Abstract 24

Objective: The aim of this scoping review is to map the current landscape of published research and 25 perspectives on physician suicide. Findings could serve as a roadmap for further investigations and 26 potentially inform efforts to prevent physician suicide. 27

Methods: Ovid MEDLINE, PsycInfo, and Scopus were searched for English-language publications 28 from August 21, 2017 through April 28, 2018. Inclusion criteria were a primary outcome or thesis 29 focused on suicide (including suicide completion, attempts, and thoughts or ideation) among medical 30 students, postgraduate trainees, or attending physicians. Opinion articles were included. Studies that 31 were non-English, or those that only mentioned physician burnout, mental health or substance use 32 disorders were excluded. Data extraction was performed by two authors. 33

Results: The search yielded 1,596 articles, of which 347 articles passed to the full-text review round. 34 The oldest article was an editorial from 1903; 210 (60.3%) articles were published from 2000 to 35 present. Authors originated from 37 countries and 143 (41.2%) were opinion articles. Most discussed 36 were suicide risk factors and culture of practice issues, while least discussed themes included public 37 health and postvention. 38

Conclusions: Consistency and reliability of data and information about physician suicides could be 39 improved. Data limitations partly contribute to these issues. Also, various suicide risk factors for 40 physicians have been explored, and several remain poorly understood. Based on this scoping review, 41 a public health approach, including surveillance and early warning systems, investigations of sentinel 42 cases, and postvention may be impactful next steps in preventing physician deaths by suicide. 43

1 Introduction 44

Physician suicide is a significant problem for the medical community and general public and is 45 poorly understood, suggesting that important knowledge and implementation gaps towards 46 prevention remain. To address this gap, this literature review aims to describe the state of current 47 knowledge and research on physician suicidal behaviors among medical students, postgraduate 48 trainees, including residents and fellows, and physicians. Suicide is estimated to occur at a higher rate 49 among physicians than the general population and perhaps even other professions (1,2), however, 50 estimates by profession vary (3). Several medical organizations have begun launching various 51 initiatives to address physician well-being, yet efforts to address physician suicide remain 52 organization- or institution-specific. The aim of this scoping literature review is to map the current 53 landscape of published research and perspectives on physician suicide. Findings could serve as a 54 roadmap for informing further study, evidence-based policy, and interventions to prevent physician 55 suicide. 56

2 Methods 57

This scoping review was conducted following the Arksey and O’Malley framework as expanded 58 upon and outlined within the Joanna Briggs Institute Reviewers’ Manual (4,5). A scoping review 59 differs from other reviews such as a systematic review which gathers and assesses the quality of 60 quantitative evidence to report on the effectiveness of a particular intervention in achieving a certain 61 outcome (6). The research question was broadly designed to gather and analyze articles that mention 62 physician suicide. No date range for the search was specified. The initial searches were performed on 63 August 21, 2017 in Ovid MEDLINE, and October 11, 2017 in Ovid PsycINFO. Authors contributed 64 seed articles that they had previously identified as relevant to physician suicide (2,7–10), which were 65



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analyzed by the medical librarian co-author. Search terms and databases were then selected and 66 tested based on this analysis. The search strategy also underwent a peer review process with two 67 additional medical librarians. An updated search was run again on April 28, 2018 in Ovid 68 MEDLINE, PsycINFO, and Scopus. Detailed search terms are available in Appendix 1. 69

Inclusion criteria were English-language papers with a primary outcome, measure, or thesis focused 70 on death by suicide or suicidal behaviors among physicians, including suicide attempts, and suicidal 71 thoughts and ideation. Physicians included medical students, postgraduate trainees (residents and 72 fellows), and physicians at any career stage. Opinion articles were also included, if they otherwise 73 met inclusion criteria; these included perspectives, letters to the editor or their replies, essays, and 74 viewpoints with a focus specifically on physician suicide. Exclusion criteria were non-English 75 publications and those only pertaining to physician burnout, mental health, substance use disorders, 76 or other media, such as newspaper and magazine articles. Query results totaled 1,596 articles after 77 deduplication. Two authors reviewed abstracts and titles to include in the the full-text review round 78 and disagreements were adjudicated by a third author [initials deleted to maintain integrity of the 79 review process]. Next, during the full-text review round, two authors again reviewed full-text articles 80 for inclusion with a third author adjudicating disagreements. Covidence, a literature review 81 management software, was used to review articles during inclusion and exclusion steps 82

Then, two authors performed data extraction (TL,SP) using a data charting table. Data extracted 83 included: primary thesis or outcome measure (e.g. death by suicide, suicide attempt, suicidal ideation 84 or thoughts), date of publication, authors’ country affiliation, type of publication, study design, 85 country of participants, tools used to ascertain outcome measures, and physician population 86 (specialties, career stage). While reviewing articles, authors used an open coding approach to tag 87 articles by key topics or themes (e.g. suicidal ideation, depression, prevention, substance use, etc.). 88 The aim was to inductively identify key themes across the published literature included in this 89 scoping review. During each subsequent round of review, tags could be added to articles. After all 90 articles were reviewed and tagged by two authors (TL,SP,CYAC), one of the authors (TL) re-91 reviewed all articles to add tags until a point of saturation was reached and no further topic tags could 92 be added. Tags were then condensed into a core set of themes. These themes were assembled into a 93 framework based on their frequency of occurrence, resulting in a map of the most published themes 94 about physician suicide. Findings are summarized in narrative form. 95

3 Results 96

The 347 articles that met inclusion criteria (Figure 1) covered a broad range of publication types over 97 time and from countries worldwide. The earliest publications were editorials (Table 1), with the first 98 published in 1903 by an unknown author. Overall, 143 (41.2%) opinion articles were published, 99 suggesting an ongoing public dialogue about physician suicide in academic journals lasting over a 100 century. Of the remaining 204 (58.8%) articles, cross-sectional study design involving a survey was 101 the most commonly used study design. Of these, 13 described interventions intended to prevent 102 physician suicide. Such articles frequently introduced the paper by describing “a tragic case,” when 103 the death of one or more physicians by suicide stimulates the development or implementation of an 104 intervention (11). 105

Authors from 37 countries published articles on physician suicidal behaviors, including: the United 106 States, United Kingdom, Finland, Norway, Sweden, Italy, Japan, Canada, China, Denmark, Hungary, 107 Brazil, Egypt, Germany, Lebanon, Pakistan, Poland, Taiwan, Austria, Belgium, Bosnia and 108 Herzegovina, India, Iran, Malaysia, Nepal, New Zealand, Portugal, Serbia, South Korea, Spain, 109



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Thailand, Turkey and the United Arab Emirates. Some countries have only published opinion articles 110 about the subject, including Israel, Nigeria, and Pakistan. Six articles were opinion articles that 111 contained no information about country of origin. 112

3.1 Ascertaining Suicidal Behaviors 113

3.1.1 Estimating Suicide Incidence 114

Death by suicide was the only primary topic in 108 (31.1%) of all articles. Non-opinion articles 115 primarily sought to estimate epidemiology of suicidal behaviors among physician populations. In 116 other words, death by suicide was most often studied among attending physicians because of 117 availability of data on occupation and death, particularly in vital statistics or death certificates. 118 However, the tools used to perform such estimates varied. Deaths by suicide were most frequently 119 estimated based on 9th or 10th Revisions of the International Classification of Diseases (ICD-9 or 120 ICD-10) codes on death certificates. Other commonly used sources of data included membership 121 masterfiles from physician organizations or associations (12), published obituaries, and charts from 122 medical records or forensic reports (Table 2). These data are primarily limited by potential 123 undercoding. Undercoding can result from deaths being coded as accidental deaths, for example, 124 leading to underestimation of the actual incidence of suicides among physicians. In an editorial, one 125 author notes, “Suicide is a way to die and not a cause of death. And there are several means to this 126 end: the ICD-10 lists at least 31 different ways to perform a suicide” (13). Rimpela et al articulated 127 this in 1987 also: “Differentiation between suicide, accident, poisoning, and violence as a cause of 128 death is often difficult, and suicide might sometimes be falsely, even deliberately, classified as an 129 accident and even differently in different occupational groups” (14). 130

Suicides are typically reported as a suicide mortality rate (SMR) in epidemiologic literature, which is 131 the number of deaths by suicide per 100,000 person-years. A suicide rate ratio can be calculated by 132 dividing the SMR among physicians, or a subpopulation thereof, and dividing by a comparison 133 group, such as the general population. Despite these standardized manners of suicide reporting, 134 included papers showed inconsistencies in reporting, often reporting a crude mortality rate, which is 135 calculated by the absolute number of physician suicides divided by the number of years in a study 136 period, then reported per 100,000 physicians. For example, in 1968 Craig and Pitts counted 228 137 suicides among physicians, based on obituary materials collected by the Deaths Editor of the Journal 138 of the American Medical Association, between May 1965 and May 1967 (15). Combined with an 139 estimation of approximately 296,000 physicians in the U.S. at the time, this resulted in a crude 140 annual suicide rate of 38.4 per 100,000 physicians (15). Multiplying this crude annual suicide rate 141 and the U.S. physician population of approximately 953,000, which was reported by a 2016 census 142 from the Federation of State Medical Boards, leads to an estimate of 366 physician deaths by suicide 143 annually. 144

Underreporting undermines the accuracy of physician suicide incidence estimates using death 145 certificates, membership files, and medical charts. Surveys also can lead to underreporting. One study 146 surveyed the deans of 116 medical schools in the 1970s about medical student suicides; 88 147 respondents reported 52 medical student suicides between 1970 and 1978 (16). Another approach to 148 studying physician suicides is psychological autopsy, in which a psychological profile about a person 149 is constructed after their death. Time-intensive and not a standard practice, psychological autopsy 150 involves collecting information through interviews of relatives and healthcare professionals, along 151 with data from forensic examinations, police investigations, psychiatry, medical and social agency 152 records, and any other information available, such as suicide notes (17). Such an approach can 153 elucidate potential contributors to an individual’s death, providing detailed contextual information, 154



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their life circumstances, and how they managed such circumstances up until their death. However, 155 psychological autopsies are not systematically applied in the setting of deaths by suicide. Case 156 reports also may describe a psychological profile, in addition to medical and clinical aspects of the 157 case (10,17,18), but this was also infrequently published. In 2013, Gold et al examined data from the 158 U.S. National Violent Death Reporting System (NVDRS), which is a combination of information and 159 data from death certificates, coroner and medical examiner reports, toxicology reports, and law 160 enforcement reports (2), the only study to triangulate multiple data sources to estimate suicide 161 incidence. The wide variety of data sources and methods of estimation suggest that there is no 162 standard. 163

3.1.2 Suicide Clusters 164

Suicide clusters are suicides that occur near each other, typically with respect to time and geography. 165 Suicide contagion refers to spread of information about a suicide via media and other channels, 166 which can increase suicide risk in a community. Only three studies acknowledged these topics. Two 167 opinion papers described suicide clusters that occurred in a short time span and in a focused 168 geographic region, one in Winnipeg, Canada (19) and another cited suicides in Australia that had 169 been reported in news media (20). Both articles focused on intense or distressing working conditions 170 as important factors in the suicide deaths but did not elaborate further on suicide clustering. In fact, 171 the Canadian article, along with one other case series of physicians who died by suicide while on 172 probation in Oregon state (21), used the term “epidemic” rather than “clusters.” Nonetheless, all three 173 papers referred to the concepts of suicide clusters and suggest contagion, even though they do not use 174 these terms explicitly. These were articles were tagged with the public health theme. 175

Suicide clusters also appeared to follow physician subpopulations, although numbers were small in 176 such case series and opinion articles. Unexpected physician subpopulations included, for example, 177 immigrant physicians (22), physician pilots (23), and physicians who experienced war either as 178 victims or as wartime medics (24,25). In 2016, Bock et al describe a case series of 62 Hungarian 179 Jewish dermatologists during the Holocaust: some emigrated, some died during Nazi rule, and others 180 survived (24). Three of these dermatologists died by suicide, which was “very common among the 181 doctors [under the Nazi ordeal], especially those physicians of the older generation” (24). Another 182 unexpected analysis described the confusing ethical circumstances of physicians as terrorists (26). 183

3.1.3 Estimating Suicidal Ideation and Attempts 184

Overall, suicidal ideation was the second most studied thesis among articles included in this literature 185 review, especially suicidal ideation among medical students. To assess suicidal ideation and attempts, 186 surveys were most commonly used; overall, 61 cross-sectional survey studies were performed (Table 187 1). Validated surveys are available to assess suicidal ideation (Table 2), however, investigator-188 developed items and surveys were also used. Only four studies compared physician subpopulations 189 between countries. In the Health and Organization among University Hospital Physicians in Europe 190 (HOUPE) study, investigators sought to compare suicidal thoughts and work-related stressors 191 between practicing physicians in Italy and Sweden (27–29). Another study compared lifetime 192 prevalence of suicidal thoughts among practicing physicians in Norway and Germany (30). 193

Suicide attempts in general were poorly studied in any physician subpopulation, but suicidal 194 behaviors among postgraduate trainees were the least studied of all, with resident physicians’ 195 behaviors studied more than fellows. Among articles reviewed, only two validated tools, Paykel’s 196 Instrument and the Beck Hopelessness Scale, were identified that were specifically designed to assess 197



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suicide attempts; otherwise, investigators developed survey items to assess respondents’ self-reported 198 attempts. 199

3.2 Physician-specific Risk Factors 200

3.2.1 Mental Health and Burnout 201

Physicians’ risk factors for suicidal behaviors, especially mental health disorders, are among the most 202 common topics of study. Gold et al examined NVDRS data and identified certain risks unique to 203 physicians compared to non-physicians: physicians were more likely to have a job problem preceding 204 death by suicide, and a greater likelihood of known mental health disorders, yet no accompanying 205 increased likelihood of antidepressant therapy (2). Additional risk factors potentially include 206 professional setbacks prior to suicide death, such as facing complaints (21,31), feeling overloaded, 207 working long hours, or being unable to cope with job responsibilities (10), or experiencing disability 208 as a result of medical illness (17,23,32). Related to these conditions, physicians are also at high risk 209 of burnout, which has been found to be associated with suicidal ideation in U.S. medical students 210 (33) and Dutch residents (34), although no direct relationship between burnout and death by suicide 211 has been established. To assess these risk factors, a variety of validated questionnaires were used to 212 inquire about general health, burnout and stress, mental health (e.g. depression, anxiety or insomnia), 213 substance use including alcohol use, and other measures of career, work, personality, and other life 214 experiences (Table 2). Additionally, investigator-developed survey questions were also used, for 215 example, to assess attitudes towards suicidal behaviors of a peer. 216

Because the earliest publications about physician suicide suggested an increased incidence compared 217 to the general population, certain theories have been applied to attempt to explain the increased 218 suicide risk among physicians. For example, Fink-Miller applied the interpersonal psychological 219 theory of suicidal behavior (IPTS) (35,36) to physician suicide. The IPTS posits three necessary and 220 sufficient precursors to death by suicide: (1) thwarted belongingness, a feeling of disconnection with 221 others, (2) perceived burdensomeness, a miscalculation that one’s death would relieve burdens on 222 others, and (3) acquired capability, habituation to previously provoked fear responses, including 223 losing the fear of pain involved in taking one’s life. This can stem from repeated exposure to painful 224 or provocative stimuli, including events triggering second victimization, such as patients’ poor 225 outcomes, death, and suffering. This can then lead to desensitization when exposed to death in 226 general. Role strain describes physician risks as a result of their direct work environment or 227 professional norms; a mismatch between social and institutional norms and the physician’s roles can 228 manifest as an unrealistic expectation of perfect function at a maximum level of competence (37). 229 Professional self-image and identity, along with self-stigma, are also considered relevant mediating 230 themes (17,23,38). 231

Early studies of suicide rates by specialty suggested that psychiatry and anesthesiology had the 232 highest suicide rates (35). Indeed, these two specialties occurred most frequently in this scoping 233 literature review, followed by surgery or general surgery. However, the findings remain mixed due to 234 data limitations in ascertaining suicide rates as noted previously (39–41). Furthermore, no 235 explanations for the association have been offered other than a proffered but unstudied hypothesis 236 that some medical specialties may possess more acquired capability than others (36,42). 237

3.2.2 Specialized Knowledge and Access 238

The access and knowledge hypothesis is a commonly discussed risk factor for suicide death among 239 physicians. Physicians acquire specialized medical knowledge of the human body and have access to 240 the means (e.g. prescription drugs) that can cause lethal self-harm. Observational studies of means of 241



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suicide death suggest that firearm, prescription drug overdose, and hanging are among the most 242 common methods used by physicians (14,35,41), although this varies by country. Psychological 243 autopsies are consistent with the access and knowledge hypothesis. One set of psychological 244 autopsies in the United Kingdom examined 38 physician suicides, finding that 28 of the physicians 245 died by self-poisoning and 11 by self-injury (other than poisoning), as one physician used both 246 methods (10). In a Finnish psychological autopsy of 7 physician suicides, only 2 had previous suicide 247 attempts, suggesting that physicians may be more likely to cause self-harm leading to death by 248 suicide; in other words, physicians who die by suicide may not have had any prior suicide attempt, 249 which is risk factor in the general population (17). Self-treatment or self-prescription is also a 250 concerning contributor due to specialized access to controlled substances, as “medical doctors exploit 251 their profession for purpose of self-treatment” (17). 252

3.2.3 Personality Traits, Upbringing, and Cultural Context 253

Personality and life experience prior to medical training might also contribute to physician suicide 254 risk, although are poorly studied. In a prospective study of Norwegian medical students, the control 255 personality trait, or the degree of compulsiveness, was independently linked to suicidal ideation; and 256 more neuroticism, or the vulnerability personality trait, as a medical student independently predicted 257 more serious suicidal ideations and planning in the first two postgraduate years (9,43,44). Reality 258 weakness, more commonly associated with serious psychiatric pathology, predicted a transition from 259 suicide ideation to planning (9). Neuroticism and tendency towards perfection may even be traits 260 sought in potential medical trainees. One editorial speculates about the influence of adverse 261 childhood experiences on risk for physician suicide (45). One South Korean study found a more than 262 threefold risk of lifetime suicidal ideation, planning, and attempts among medical students who 263 experienced emotional abuse early in life, characterized by “a continuously cold and uncaring 264 parental attitude” (46). In China, medical students were surveyed about parental relationships and 265 parenting communication styles, hypothesizing that this could be a highly influential aspect of the 266 student’s character (47). The study found that for Chinese medical students, a good relationship with 267 parents was statistically significantly associated with less suicidal ideation, plans and attempts. 268

Some studies sought to identify risk factors unique to their cultural context. Researchers in the United 269 Arab Emirates collaborated with Eskin (48) to again assess medical students’ religiosity and their 270 attitudes towards suicide (49). In this study, investigators suggested that the Islamic faith may serve 271 as a protective factor against suicidal thoughts and death by suicide among their medical students. In 272 Pakistan, a study of suicidal ideation among medical students included religion as a demographic 273 characteristic but did not otherwise include religion in further analyses (50). Among opinion articles, 274 certain conceptualizations of suicide also varied. For example, in one commentary from Japan, two 275 concepts directly link overwork with death: karoshi (death due to overwork) and karojisatsu (suicide 276 due to overwork) are considered causes of death in the Japanese culture (51) but nowhere else in the 277 world. 278

3.2.4 Gender 279

Early studies in the 1970s and earlier explicitly excluded female and minority physicians (43,52,53). 280 Results published in 1999 from the Women Physicians’ Health Study, which surveyed a sample of 281 women physicians from the American Medical Association masterfile (54), described prior studies 282 that reported an odds ratio as high as 4 for women physician suicides compared to other categories of 283 women but that such studies were based on small numbers of suicide deaths. In 2004, Schernhammer 284 performed a systematic review and meta-analysis, concluding that the suicide rate ratio for women 285 physicians was 2.27 compared to the general women population, and 1.41 for male physicians 286



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compared to the general male population (1). The 1999 study found that women physicians had 287 similar rates of depression compared to the general population but had lower numbers of suicide 288 attempts (54); the authors postulate that women physicians may have less suicidal intent or a higher 289 rate of completion than the general population, although the study’s scope did not include these 290 outcomes. In 2013, a Polish study of perimenopausal female physicians examined sociodemographic 291 and lifestyle variables’ relationship to participants’ subjective sense of health, including suicidal 292 ideation. Eight of 221 participants reported suicidal thoughts, which was statistically significantly 293 correlated with poorer subjective sense of health (55). Another study in Pakistan appeared to show no 294 gender difference in terms of rates of suicidal ideation among medical students (56). Little data is 295 known on suicide among physicians of gender minorities, as only one perspective piece written by a 296 nurse who wrote about her transgender child who died by suicide (57). 297

3.3 Themes in Physician Suicide Literature 298

This scoping literature review revealed several themes in physician suicide literature, with greatest 299 attention to identifying risk factors, such as mental health. Culture of practice and context of suicide, 300 which include, for example, mental health stigma, physician attitudes towards suicide, and job 301 conflicts, also were subjects of increased focus. These and the remaining themes identified are 302 illustrated in Figure 2, where the most common themes are positioned at the broadest (top) level of an 303 inverted pyramid. With each successive level of the inverted pyramid, fewer papers describe such 304 issues. We chose an inverted pyramid to illustrate how the weight of the risk factors for physician 305 suicides are balancing precariously over the vertex, where less attention on postvention and public 306 health initiatives for surveillance and prevention. This imbalance quickly identifies potential areas for 307 further work. Themes such as suicide as a public health issue, postvention, and legal issues were far 308 less studied than others. 309

In the second level of the framework are epidemiologic and demographic focuses for study, which 310 were previously described in section 3.2. Along with these subjects are a relatively lesser focus on 311 substance use, compared to other risk factors such as mental health, and on developing educational 312 curricula to address knowledge gaps about suicide and its prevention. Wellness is an increasingly 313 popular topic for publication on this level of the framework. In the third level of the framework are 314 prevention approaches. Thirteen articles described interventions with a primary aim of preventing 315 physician suicides. Frequently, programs were implemented as an organizational response to a 316 physician suicide. Five interventions implemented the AFSP’s Interactive Screening Program for 317 suicide prevention (58,59) as a component of a larger initiative to promote physician well-being; 318 three of the five came from the same institution (60–62). Only one of 13 was a randomized controlled 319 trial of a web-based screening program (63). 320

Treatments and responses to physician suicide were discussed as frequently as prevention; treatments 321 and responses differed because treatments tended to focus on individual physician treatment for 322 suicidal behaviors or related mental health disorders, and responses tended to focus on small group, 323 physician health program, or medical board responses to individual circumstances. For example, 324 Young et al described the difficult grieving process for a healthcare team after the death a physician 325 (64). Patients were told that the physician who had died “was not available,” trust between staff and 326 administrators eroded, morale decreased, and grieving, guilt and other negative consequences 327 remained unaddressed until six weeks after the physicians’ death (64). The process of facilitating a 328 normal grieving process after a suicide death has occurred requires active planning, called 329 postvention. In another study by Kaltreider et al, 20 medical students were interviewed after the death 330 of a classmate by suicide (65). This qualitative study found that students experienced intense, 331



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intrusive, and persistent thoughts and emotions relating to their classmate’s death, sometimes lasting 332 for months. Proximity to the site of the death, prior exposure to another suicide previously, or 333 familiarity with depression in themselves or family seemed to increase these effects. 334

Legal and policy issues are increasingly recognized as affecting physician health and well-being, and 335 appear in the third and fourth levels of Figure 2. Physicians may avoid seeking mental health 336 treatment, avoid self-report, and self-treat mental health and other health issues (66,67), out of fear of 337 reputational damage or concern about perceived weakness or impairment (68). Licensure application 338 questions could be improved (68) and compassionate, confidential assistance programs, such as one 339 implemented in the United Kingdom in 2010, could offer bespoke services to physicians who might 340 be considered at risk of suicide (67). In 2015, the UK’s General Medical Council was recommended 341 to fund a pilot program that would include developing a national support service for doctors (69). 342 However, no literature was found to describe such policies in other countries. 343

Only three articles describe suicide clustering and suicide contagion, which are unique public health 344 concepts pertaining to suicide (19–21). However, no further follow-up or other literature regarding 345 these suicide clusters were found in this scoping review. As a result, the themes of postvention and 346 public health approaches to physician suicide both were at the vertex (bottom) of the inverted 347 pyramid. 348

4 Discussion 349

As a scoping literature review, this review did not include a quality assessment of quantitative 350 evidence from included papers nor did it perform a meta-analysis or any statistical comparisons of 351 published evidence, which would be characteristic of a systematic review (6). More papers on 352 physician suicide have been published over the last two decades than before. This follows an overall 353 trend in published literature on physician well-being and may also reflect growing public recognition 354 of and decreasing stigma relating to suicide. Furthermore, the proportion of opinion articles 355 published is lower in the recent past compared to previously, indicating growing application of 356 contemporary statistical and scientific methods to the study of physician suicide. Nonetheless, themes 357 identified reveal opportunities for further work. The inverted pyramid framework (Figure 2) suggests 358 that there is a dearth of work on examining physician suicide using typical public health approaches 359 to investigate suicide clusters. 360

Figure 3 offers a proposed framework that highlights priorities for continued work on physician 361 suicide. This framework highlights the potential for developing an organized public health approach 362 to preventing physician suicide. The pyramid’s base identifies areas for immediate, targeted actions, 363 forming the foundation for the following recommendations for action: 364

• Mandatory reporting, an approach used for workplace injury reporting, which could 365 improve surveillance of physician deaths by suicide (prevention); 366

• Identification of minimum acceptable community standards of validated instruments 367 to assess suicidal ideation and attempts (prevention, public health); 368

• Development and implementation of evidence-based screening and service provision 369 for suicide risk factors (58–63) (prevention); 370

• Development of early warning systems, like those used to monitor infectious disease 371 outbreaks, to signal suicide clusters and contagion (public health); 372

• Implementation and dissemination of best practices, especially regarding postvention 373 or additional directed interventions (postvention); 374



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• Increase education in the healthcare community about suicide warning signs and 375 prevention (education, wellness); 376

• Standardized education in the medical community about appropriate reporting on 377 suicides to prevent suicide contagion (education); 378

• Reduction of barriers to help-seeking behavior, reduce systematic stigma in licensing 379 and investigative processes (policy issues, legal issues). 380

Higher levels in Figure 3 include continued study of persistent risk factors, contextual and cultural 381 challenges, social factors like family, and health inequities resulting from gender, immigrant, or other 382 minority status, among other concerns. Currently available information is insufficient to draw 383 conclusions about physician subgroups or their cultural or health system contexts. Such information 384 on understudied physician subgroups could better inform future revisions of public health, 385 prevention, and postvention programs to include diversity-sensitive suicide prevention approaches. 386

The strengths of this scoping literature review are its breadth and inclusiveness in examining multiple 387 types of published literature in scholarly journals. However, due to the volume of citations generated 388 by the searches, we excluded grey literature (e.g. conference proceedings, poster presentations, etc.) 389 and snowballing of references was not performed. Additionally, physician suicide involves multiple 390 disciplines, and searching additional electronic databases of peer-reviewed and non-peer-reviewed 391 literature may be appropriate for future updates of such a literature review. Finally, additional articles 392 have been published on physician suicide since the end of the search period of April 2018. Excluding 393 non-English language publications may have led to overrepresentation of countries where English is 394 the official language. Among the 46 non-English language papers excluded (Figure 1), potentially 395 relevant papers were published in German, Spanish, Dutch, Finnish, Japanese, Chinese, French, 396 Swedish, and Hungarian, which could reveal relevant themes in physician suicide, including cultural 397 or health system context. Future studies could identify opportunities for cross-disciplinary and cross-398 cultural learning and suicide prevention. 399

5 Conclusion 400

This scoping review offers a landscape view of physician suicide literature and opportunities for 401 further work on physician suicide prevention. Interventions are needed at multiple levels to mitigate 402 the risks of physician suicide, which could begin with an organized public health approach. As a part 403 of such an approach, consistency and reliability of data and information about physician suicides 404 could be improved. Data limitations partly contribute to these issues. For example, annual rates of 405 physician suicide reported and quoted may result from extrapolated estimates from old data, such as 406 those collected by Craig and Pitts in 1968 (15). Reliable and trackable data and information can 407 provide more continuously updated insights into actual suicide mortality rate ratios of physician 408 suicide compared to other populations (70). Also, systems could be developed to better monitor 409 physician suicides, offer early warnings of possible suicide clusters or contagion, and may improve 410 investigation and interventions for the benefit of physicians’ and public health. Physician suicide 411 should be approached as a public health issue and as a shared responsibility between individuals and 412 institutions to prevent physician deaths by suicide. 413

6 Author Contributions 414

TIL, SP, and CYAC designed the study and performed study selection. RS performed the literature 415 search. TIL and SP extracted data, TIL performed computational analyses, and TIL, SP, and CYAC 416 interpreted the data. TIL drafted the manuscript, except for the Methods section which was drafted by 417



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RS, and the entire manuscript was produced with critical revisions and important intellectual content 418 from all authors. 419

7 Acknowledgments 420

The authors wish to acknowledge Dr. Christine Moutier and Dr. Srijan Sen for their critical review 421 and feedback on the manuscript, as well as Dr. Matthew Goldberg for his early contributions to the 422 background and initial design considerations for this review. 423

8 References 424

1. Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender 425 assessment (meta-analysis). Am J Psychiatry [Internet]. 2004 Dec;161(12):2295–302. 426 Available from: http://www.ncbi.nlm.nih.gov/pubmed/15569903 427

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Fig. 1 PRISMA diagram of study selection for inclusion



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Table 1. Article characteristics from scoping review of literature on physician suicide, 1903-2018

Publication date range 1900-1919 1920-1949 1950-1959 1960-1969 1970-1979 1980-1989 1990-1999 2000-2009 2010-2018

No. (%) of non-opinion articles 0 0 0 5 (2.4%) 24 (11.7%) 20 (9.8%) 26 (12.7%) 42 (20.5%) 88 (42.9%)

No. (%) of opinion articles 1 (0.7%) 1 (0.7%) 0 9 (6.3%) 19 (13.3%) 18 (12.7%) 14 (9.9%) 37 (26.1%) 43 (30.3%)

Study design or publication type Cross-sectional studies Survey-based Review Narrative Case report or case series Case-control Cohort studies Intervention† Other††

No. (%) of non-opinion articles 85 (41.5%) 63 34 (16.6%) 30 22 (10.7%) 19 (9.3%) 14 (6.8%) 13 (6.3%) 18 (8.8%)

No. (%) of opinion articles N/A

†Publications about an intervention at minimum describe the intervention. ††Other study designs included: qualitative studies or psychological autopsy (n=8), validation or evaluation of a survey instrument or screening question (3), news coverage (4), poetry (1), a discussion guide (1), or a correction (1).



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Table 2 Methods of ascertainment of suicidal behaviors and related risk factors, for 204 non-opinion publications

Methods of ascertainment

Suicide death Death certificates (vital statistics by U.S. state or non-U.S. country) Forensic, pathology, or autopsy reports, e.g. from a medical examiner’s office Medical chart reviews of physician patients Professional membership masterfiles Obituaries published in journals (e.g. JAMA) Family confirmation or interviews

Suicide attempt Paykel’s Instrument (assesses suicidal ideation and suicide attempts) Beck Hopelessness Scale Investigator-developed question(s) or questionnaire

Suicidal thoughts or ideation Patient Health Questionnaire 9 Beck Scale for Suicidal Ideation Acquired Capability for Suicide Scale Self-harm Behavior Questionnaire Suicidal Behaviors Questionnaire Investigator-developed question(s) or questionnaire



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Fig. 2 Framework of common publication themes on physician suicide



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Fig. 3 Proposed framework to highlight foundational priorities for continued work on physician suicide



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physician suicide: a scoping review to highlight ...€¦ · 29/08/2019 · physician suicide: a...

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